Referral / Intake Form

Personal and Home Support: Intake Form

Personal Care and Homemaking Support
About You
Name*

First NameLast Name
Birth Date*

MonthDayYear
Address

Street Address

Street Address Line 2

CityProvince

Postal Code
Phone Number*

Area CodePhone Number
Email
example@example.com
Ethnicity*
Language*
Your preferred language
Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Relationship*
What is the relationship of your emergency contact to you (spouse, partner, son, daughter, friend, etc.)?
Living Arrangements
Living Arrangement*

Live AloneWith Spouse / PartnerWith Family / FriendWidowedAssisted LivingHospitalOther
Do you have access to the Internet?*

YesNo
Ways you have access to the Internet?

Computer or LaptopiPad or TabletSmartphoneOther
Do you have any pets?*

YesNo
Are you a smoker?*

YesNo
Do you use any other in-home services?*

Personal Support Worker (PSW)Nursing ServicesPhysiotherapyOccupational TherapistNoOther
Medical Information / Concerns
Medical Information
Please provide us with any medical information that would help us find you the best programs & support.
Health Concerns

Please tell us about any health concerns you may have.
Mobility*

NoOther
Vision Impairment*

NoOther
Hearing Impairment*

NoOther
Speech Impairment*

NoOther
Please list any allergies that require regular treatment and medication:
Are you completing this form for yourself or are as a Substitute Decision Maker (SDM)?*

MyselfSDM on behalf of client
SDM has provided consent for referral to Re-Imagine Ontario?

YesNo
Referee's Name

First NameLast Name
Referee's Title
Referring Organization's Name
Referee's Email
example@example.com
Referee's Phone Number

Area CodePhone Number
Income Information
What is the approximate yearly combined household income?*

Less than$14,999 ($1,249/month)$15,000 –$19,999 ($1,249-1,667/month)$20,000–$24,999 ($1,668-2,083/month)$25,000 –$29,999 ($2,084-2,500/month)$30,000 -$34,999 ($2,501-2,916/month)$35,000 -$39,999 ($2,917-3,333/month)$40,000 –$59,999 ($3,334-4,999/month)over$60,000 (over 5,000/month)Do not knowPrefer not to answer
How many people are supported by this income (including yourself)?*
Are you struggling to meet your basic needs?*

YesNo
What is/are your source(s) of income?*

EmploymentEmployment Insurance (EI)Old Age PensionWSIBOntario Works (OW)Ontario Disability (ODSP)PP DisabilityCPP / OASFriendsSpousal SupportFamily / SpouseOther
Today's Date*

YearMonthDay
Should be Empty:

Personal and Home Support: Intake Form

Emergency Contact Information

Living Arrangements

Medical Information / Concerns

Health Concerns

Income Information